Provider Demographics
NPI:1972088912
Name:COLLABORATIVE PSYCH & MED
Entity type:Organization
Organization Name:COLLABORATIVE PSYCH & MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:855-732-5292
Mailing Address - Street 1:4406 S FLORIDA AVE STE 31
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2176
Mailing Address - Country:US
Mailing Address - Phone:855-732-5292
Mailing Address - Fax:863-583-9926
Practice Address - Street 1:4406 S FLORIDA AVE STE 31
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2176
Practice Address - Country:US
Practice Address - Phone:855-732-5292
Practice Address - Fax:863-583-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty